Female sex workers exposed to community mobilization less exposed to sexually transmitted infections

Community mobilization and empowerment of female sex workers in Karnataka state, south India: associations with HIV and sexually transmitted infection risk. 

Beattie TS, Mohan HL, Bhattacharjee P, Chandrashekar S, Isac S, Wheeler T, Prakash R, Ramesh BM, Blanchard JF, Heise L, Vickerman P, Moses S, Watts C. Am J Public Health. 2014 Jun 12:e1-e10. doi:10.2105/AJPH.2014.301911 [Epub ahead of print]

Objectives: We examined the impact of community mobilization (CM) on the empowerment, risk behaviors, and prevalence of HIV and sexually transmitted infection in female sex workers (FSWs) in Karnataka, India.

Methods: We conducted behavioral-biological surveys in 2008 and 2011 in 4 districts of Karnataka, India. We defined exposure to CM as low, medium (attended nongovernmental organization meeting or drop-in centre), or high (member of collective or peer group). We used regression analyses to explore whether exposure to CM was associated with the preceding outcomes. Pathway analyses explored the degree to which effects could be attributable to CM.

Results: By the final survey, FSWs with high CM exposure were more likely to have been tested for HIV (adjusted odd ratio [AOR] = 25.13; 95% confidence interval [CI] = 13.07, 48.34) and to have used a condom at last sex with occasional clients (AOR = 4.74; 95% CI = 2.17, 10.37), repeat clients (AOR = 4.29; 95% CI = 2.24, 8.20), and regular partners (AOR = 2.80; 95% CI = 1.43, 5.45) than FSWs with low CM exposure. They were also less likely to be infected with gonorrhea or chlamydia (AOR = 0.53; 95% CI = 0.31, 0.87). Pathway analyses suggested CM acted above and beyond peer education; reduction in gonorrhea or chlamydia was attributable to CM.

Conclusions: CM is a central part of HIV prevention programming among FSWs, empowering them to better negotiate condom use and access services, as well as address other concerns in their lives.

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Editor’s notes: Community mobilization is a group empowerment strategy that focuses on the structural drivers of HIV transmission. Starting in 2003, the Karnataka Health Promotion Trust in India collaborated with female sex workers to recruit peer educators. This led to the creation of drop-in centres, distribution of presumptive treatment of gonorrhoea and chlamydia infection, and ultimately the formation of locally-sustained collectives and community-based organisations. In 2011, half of female sex workers in Karnataka were members of one of these groups. Members of these groups were more likely to have used condoms with their sex partners and were less likely to contract either gonorrhoea or chlamydia. The findings suggest that community mobilization may work because it is strongly associated with both collective (power with) and individual (power to) empowerment of sex workers. This is one of the first studies of community engagement to include biological outcomes for HIV and sexually transmitted infection, rather than self-reported measures of behaviour that may be susceptible to bias. The results suggest that such community empowerment approaches may form an integral part of HIV prevention programming in sex worker communities. 

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